Student Summary of Responsibilities Form

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Items marked * are required fields!

I have read and understand the policies governing my participation in the Cooperative Education and Internship Program at the University of Massachusetts Dartmouth University and hereby apply for admission. If accepted, I agree to abide by the policy statements and responsibilities listed below as conditions for admission to and continuation in the program.

1.
*

Enter and continue in the Cooperative Education and Internship Program in good faith and in fairness to both my employer and University of Massachusetts Dartmouth.

2.
*

Maintain a satisfactory academic record with the the University of Massachusetts Dartmouth and a satisfactory job performance record with my employer.

3.
*

Act in an ethical and professional manner as a representative of the University of Massachusetts Dartmouth and my employer.

4.
*

Follow the required work session/academic session schedule of the Coop/Internship Program as specified by my College/Department.

5.
*

Register for each of the required work sessions as specified by my College/Department and pay the required registration and service fee.

6.
*

Submit the required Evaluation and Work Experience Reports to my Faculty Coordinator immediately after each work session.

7.
*

Keep a current mailing address, phone number, and Email address with my Faculty Coordinator at all times.

Last Name

*

First/Middle Name

*(First Middle)

Student Identification Number

*(NOT your SSN)

School Email

@umassd.edu*

Major

Coordinator Last Name

*

Coordinator First/Middle Name

*(First Middle)

I understand that under the Family Rights and Privacy Act of 1974, I have the right to inspect and review any records that are sent out of the University directly related to me. I hereby waive these rights regarding my resume, records, grades, or evaluations which: (1) may be provided to an employer as the basis for my application for Coop/Internship employment; (2) may be provided to or received from my Coop/Internship employer for the purpose of evaluating my progress while in the Coop/Internship Program.